OVERVIEW

Mass media are increasingly intertwined with the lives of both adults and children. Whether subtly or overtly, media content (from children’s cartoons to television news) affects the public’s perceptions of mental illness and mentally ill persons, as well as the expectations patients bring to psychotherapy. Media messages can be harmful to health by fanning fears of crime and terrorism, triggering suicide attempts, or modeling violent behavior. But the various forms of mass and targeted media also offer us new and powerful public health, educational, and psychotherapeutic tools.

This chapter addresses several issues: the role of the mass media in stigmatizing mental illness and discouraging help seeking; the influence of media coverage of suicide; how media (especially television and video games) may affect aggression and violence among youth; the use of “media literacy” principles and new technologies to limit potential harms and increase benefits of media use for children; and how psychiatrists (through planned media campaigns or individual efforts) can use media intelligently to educate the public.

HOW THE MASS MEDIA AFFECT PUBLIC UNDERSTANDING OF MENTAL ILLNESS

Surveys in the United States and elsewhere have found that many people have little understanding of what mental illness looks like, what symptoms characterize different illnesses, and what is meant by labels, such as “schizophrenia” and “mania.”¹ Despite some progress in recent years, stigmatizing myths about causality persist. For example, a surprisingly large percentage of the general public believes that schizophrenia and depression are caused by “the way a person was raised” or are due to “one’s own bad character.”² They also tend to underrate the contribution of biological factors.¹ Many people harbor a distorted view of the nature and value of psychiatric treatment. While surveys show generally positive views of psychotherapy, misconceptions about medication (e.g., exaggerated concerns about side effects and a belief that drugs merely cover up symptoms) are rampant.³

The stigma associated with mental illness is a major reason that many sufferers never seek treatment, do not follow treatment recommendations, or drop out of treatment prematurely (Figure 92-1).⁴ Children with mental health problems (and their parents) face disdain, blame, and discrimination, in stark contrast to attitudes toward children with “physical” illnesses.⁵ Research has shown that inaccurate perceptions by parents and teachers regarding children’s mental health problems, and beliefs about treatment (including concerns about stigma that arises from treatment), create major barriers to receiving needed services.⁶ Given that over three-quarters of children with mental health needs do not receive treatment,⁷ the removal of barriers to care is a critical priority.

Figure 92-1 Two factors that may influence whether a person who might benefit from mental health treatment actually seeks it.

(Redrawn from Corrigan P: How stigma interferes with mental health care, Am Psychologist 59:614-625, 2004.)

A number of studies point to mass media content as a major source of stigmatization and misinformation. Among people who have little firsthand experience with mental illness, beliefs about what mentally ill people are like and how they should be treated may be shaped primarily by what is read, seen, or heard in the mass media. Reviews of press coverage in the United States, United Kingdom, Canada, and New Zealand have found that mental illness is frequently linked with violence.⁸ In one United States study on the reporting of mental illness by major newspapers, the focus of the stories was crimes or violence perpetrated by a mentally ill person 26% of the time, and it was by far the most common theme.⁹ This increases the desire to avoid persons with mental illnesses.¹⁰

Another study of United States newspapers found that the word “schizophrenic” is commonly used as a metaphor in a way that perpetuates perceptions of that illness as a “split personality” (Table 92-1).¹¹ Moreover, hostile media reports can increase self-stigma, as well as discrimination, as perceived by people who struggle with mental illness.¹²

Table 92-1 Types of References to Cancer and Schizophrenia in United States Newspapers

* X² = 579.12, df = 7, p < .001

From Duckworth K, Halpern JH, Schutt RK, Gillespie C: Use of schizophrenia as a metaphor in U.S. newspapers. Psychiatric Services 54:1402-1404, 2003.

Entertainment media can also reinforce harmful images and beliefs. For example, a review of Disney animated films found a surprisingly high number of stigmatizing comments, including “crazy” thoughts, ideas, behaviors, or clothing, with the implication that these traits were irrational and inferior.¹³ Children’s cartoons often portray “twisted” or “nuts” characters as evil or funny.¹⁴ Even video games feature negative stereotypes.¹⁵ Mental illness is a common theme in movies (including horror films) that are popular with adolescents. These not only present persons with mental illnesses as scary and dangerous, but also distort the public’s perceptions of mental health professionals and their expectations about the nature and outcome of therapy (Table 92-2).^16,17 Media portrayals of electroconvulsive therapy (ECT) have been particularly distorted. ECT is routinely portrayed in films as brutal and punishing, and even as a method of murder, with no therapeutic benefit.¹⁸

Table 92-2 Schneider’s Typology of Movie Psychiatrists and Psychologists

From Schneider I: The theory and practice of movie psychiatry, Am J Psychiatry 144:996-1002, 1987.

HOW MASS MEDIA INTERVENTIONS CAN AFFECT STIGMA

People who are more familiar with mental illness (e.g., due to personal experience; illness of family, friends, co-workers, or neighbors; or exposure through volunteer or professional work) are less likely to want to distance themselves from people with mental illness, including those with major depression.¹⁹ This also seems to be true after “virtual” exposure to models through educational videos.²⁰ Drawing on this research, and the research noted previously on the roots of stigma, the goal of many recent educational interventions has been to make the public feel comfortable with mentally ill individuals, and to refute stigmatizing ideas about the causes and treatment of mental illness.

The planning of anti-stigma initiatives has become more sophisticated, with efforts to target key attitudes or behaviors of specific populations.²¹ One approach is to reach out through the mass media (using television, radio, films, and the Internet). The World Psychiatric Association’s (WPA’s) Programme to Reduce Stigma and Discrimination Because of Schizophrenia, begun in 1996, has programs in over 20 countries.²² The WPA recommends a “social marketing” approach to planning outreach campaigns that includes targeting specific subgroups (e.g., criminal justice personnel), conducting needs assessments to inform the design of media messages, and pretesting media materials before embarking on expensive campaigns.

The Royal College of Psychiatrists in Great Britain has sponsored several campaigns, including Defeat Depression from 1992 to 1996²³ and Changing Minds from 1998 to 2003.^24,25 Surveys found encouraging, but small, shifts in attitudes (e.g., regarding perceptions of dangerousness, and whether a mentally ill person is to blame for his or her condition). Perhaps the most-studied anti-stigma campaign is New Zealand’s Like Minds, Like Mine.^26,27 This research-based campaign includes strategically placed television, radio, and cinema advertisements (some featuring nationally known and respected people who had experience with mental illness), public relations activities to support the advertising messages (including media interviews and placed articles), and more targeted locally based education and grassroots activities. National tracking surveys found that awareness of campaign messages was high and that significant changes in attitudes and behavior were evident, as were reports of reduced stigma and discrimination.

It is critical to note that simply teaching facts about mental illness is not sufficient to dispel stigma. Despite their greater knowledge, psychiatrists and other mental health professionals often hold more stigmatizing attitudes toward the mentally ill than do members of the general public.²⁸ It is also important to monitor anti-stigma efforts for the creation of unintended harmful effects. For example, recent research suggests that labeling mental illnesses as biologically based “brain diseases” could increase perceptions of dangerousness and the desire for social distance from mentally ill persons.²⁹ Similarly, comparison of mental illness to chronic illnesses (such as diabetes and allergies), if overemphasized, could inappropriately discount the effects of mental illness, and create new misperceptions.³⁰

EFFECTS OF MASS MEDIA ON SUICIDE

A large body of multinational research demonstrates unequivocally that exposure to media reports of suicide can increase suicide attempts and deaths. Research reviews have found that stories of both fictional and real-life suicides can lead to imitation, but the effect of news stories tends to be greater.^31,32 Several factors seem to increase the likelihood of imitation; these include stories of celebrities (entertainers or politicians) who commit suicide; extensive, prominent news coverage of the suicide; coverage that glamorizes or sensationalizes the suicide; and detailed descriptions of the suicide method. Imitation is decreased if the negative consequences of suicide (such as disfigurement of the body, a cult-related suicide, or suffering of and condemnation by the survivors) are portrayed. Adolescents and young adults may be particularly prone to imitate suicides that are portrayed in the media, especially when the stories are of victims in their age-group.³³

A 1-year study of over 4,600 newspaper, radio, and television reports related to suicide in Australian media found a larger effect from television stories than either radio or newspapers (contrary to some earlier studies that found newspaper stories more influential).³⁴ A greater effect was also seen when multiple reports of suicide occurred close together, and when stories addressed completed suicides as opposed to suicide attempts or ideation.

Evidence suggests that changing the content and tone of news coverage of suicide can affect suicide rates. In Vienna, the opening of a new subway system led to an increase in subway suicides that was exacerbated by dramatic media reports. Creation of a suicide prevention media campaign, and guidelines for news reporters, led to a dramatic decrease in attempted and completed subway suicides.³⁵ New guidelines for media reporting on suicide suggest ways that psychiatrists can help educate the public.³⁶ When interviewed by reporters, it is important to stress the connection between mental illness (especially depression) and suicide, and to provide information on resources to prevent suicides and to help survivors of suicide. One should avoid weighted language, such as “committed,” “failed,” or “successful” when describing suicide; these words imply criminality or judgment of outcomes, which makes it difficult to put suicide into the content of mental health.

EFFECTS OF MEDIA CONTENT ON CHILDREN’S BEHAVIOR

For modern American children, interacting with mass media is essentially a full-time job. A 2005 national survey of children (ages 8 to 18) about their media use found that children devote an average of nearly 6.5 hours per day to contact with media (including print material) (Figure 92-2).³⁷ About one-quarter of children’s media time involved “multitasking,” or using multiple media at the same time. Despite the proliferation of new media, watching live or prerecorded content on television still claims the largest piece of media time: nearly 4 hours per day. Two-thirds of children had a television in their bedroom at home; these children spent more time watching television and less time reading than did their peers. Encouragingly, time spent with media did not appear to take time away from parents, friends, sports, or peers; in fact, heavy media users were more likely to interact with others. However, another recent study found that the amount of time children under age 12 spent watching television, alone or with parents (measured via media diaries completed by caregivers), was negatively correlated to time spent with parents on other activities.³⁸